Pain management for blunt thoracic trauma: Guideline

Question 1

In adult patients with blunt thoracic trauma (P), does epidural analgesia (I) versus nonregional modalities of pain control (C) (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) improve analgesia, decrease pulmonary complications and need for mechanical ventilation, shorten length of stay, and/or decrease mortality (O)?

Recommendation

In adult patients with blunt thoracic trauma, the guideline authors conditionally recommend epidural analgesia over nonregional modalities of pain control (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, NSAIDs) for the treatment of pain. This recommendation is based on very low-quality evidence but places a high value on patient preferences for analgesia. If certain confounders (or effect modifiers) such as age, number of rib fractures, or severity of injury are considered, a stronger positive magnitude of effect may be observed for certain outcomes of interest.

PICO Question 2

In adult patients with blunt thoracic trauma (P), does paravertebral block (I) versus nonregional modalities of pain control (C) (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, NSAIDs) improve analgesia, decrease pulmonary complications and need for mechanical ventilation, shorten length of stay, and/or decrease mortality (O)?

Recommendation

It is important to note that paravertebral block had equivalent pain control compared with epidural analgesia and provided significant pain relief compared with baseline. While desirable consequences probably outweigh undesirable consequences, because of the lack of studies comparing paravertebral block to nonregional pain control modalities, the guideline authors are unable to make a recommendation regarding the use of paravertebral blocks.

PICO Question 3

In adult patients with blunt thoracic trauma (P), does continuous intrapleural infusions of local anesthetics (I) versus other regional modalities of pain control (C) (i.e., epidural or paravertebral nerve blocks) improve analgesia, decrease pulmonary complications and need for mechanical ventilation, shorten length of stay, and/or decrease mortality (O)?

Recommendation

There is limited available literature regarding intrapleural analgesia for blunt thoracic trauma. The few studies that were identified were of very poor methodological quality. Because of insufficient evidence, the guideline authors are unable to make a recommendation.

PICO Question 4

In adult patients with blunt thoracic trauma (P), does multimodal analgesia (I) (i.e., use of different classes of analgesics, including combinations of opioids with other agents such as NSAIDs, pregabalin/gabapentin, acetaminophen) compared with opioids alone (C) improve analgesia, decrease pulmonary complications and need for mechanical ventilation, shorten length of stay, and/or decrease mortality (O)?

Recommendation

Although the quality and quantity of evidence for the use of multimodal analgesia in adult patients with blunt thoracic trauma are very limited, the guideline authors conditionally recommend this modality. This recommendation is based on very low-quality evidence but places a high value on patient preferences for analgesia. There is some indirect evidence that multiple analgesic modalities (i.e., transdermal fentanyl, NSAIDs), when combined, decrease pain in patients with blunt thoracic trauma. Use of alternative agents for patients with refractory pain is consistent with the clinical experience of the group, as patients often seek alternatives when a standard sole opioid regimen fails. Moreover, standard sole opioid regimens are often associated with adverse effects, especially as doses are escalated, thus requiring consideration for additional nonopioid analgesics.

PICO Question 5

In adult patients with blunt thoracic trauma (P), does continuous intercostal infusions of local anesthetics (I) versus nonregional modalities of pain control (C) (i.e., intravenous or enteral analgesics such as opioids, acetaminophen, NSAIDs) improve analgesia, decrease pulmonary complications and need for mechanical ventilation, shorten length of stay, and/or decrease mortality (O)?

Recommendation

Because of the lack of studies that fulfilled the inclusion criteria, no evidence profile was created. Because of insufficient evidence, the guideline authors are unable to make a recommendation.